Health inspection·December 7, 2023

F 0880 looked for eye protection, but was unable to find any. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 12/06/23 at 10:48 A.M. with Chief Clinic Officer (CCO) revealed two yellow isolation gowns hanging on the inside of Resident #15's room. The CCO acknowledged it was an isolation room and there should not be gowns hanging on the inside of the door. The CCO verified proper procedure was for one time use and gowns would either be disposed of or laundered. Observation was also made of a box of KN-95 masks in the top drawer of a three-drawer isolation cart in front of Resident #20's room, which the CCO verified as an isolation room which required an N-95 mask. CCO confirmed the facility had N-95 masks available. Residents Affected - Many Observation on 12/06/23 at 10:54 A.M. was made of Maintenance Assistant (MA) #17 stocking isolation carts on hall #2. Interview with MA #17 revealed he was stocking the COVID-19 isolation carts with N-95 masks, surgical masks and face shields. MA #17 stated he was unsure whose responsibility it was to stock the carts, but he was asked today by the manager to do so. Observation on 12/06/23 at 10:54 A.M. was made of Maintenance Manager (MM) #9 stocking isolation carts on hall #2. Interview at 10:59 A.M. with MM #9 revealed the carts had KN-95's and he was stocking them with N-95's as well as other needed PPE. Observation and interview on 12/07/23 at 8:32 A.M. with STNA #14 revealed the staff was exiting Resident #22's room. Resident #22 had a droplet isolation sign taped to an isolation cart outside the door. STNA #14 was observed wearing a KN-95 mask. STNA #14 verified she did not remove the mask after providing care to Resident #22 who is a COVID-positive resident. STNA #14 also confirmed she was wearing a KN-95 and not a N-95 in Resident #22's room. Review of CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed health care providers (HCP) who enter the room of a patient with suspected or confirmed COVID-19 or SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N-95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Doffing (taking off) of PPE revealed HCP should remove gloves, gown prior to exiting the room, perform hand hygiene, remove face shield and remove and discard respirator. 2. Interview on 12/07/23 at 8:31 A.M. with Housekeeper #19 revealed she worked full time at the facility. Housekeeper #19 shared she was informed by her manager housekeepers were not responsible for cleaning the COVID-19 isolation rooms, and the STNA's would clean them. Interview on 12/07/23 at 10:04 A.M. with Housekeeper #20 revealed she worked full time at the facility. Housekeeper #20 shared she was informed by her manager housekeepers were not responsible for cleaning the COVID-19 isolation rooms, and the STNA's would clean them. Interview on 12/07/23 at 10:09 A.M. with STNA #21 revealed it was the responsibility of housekeepers to clean the COVID-19 rooms, she denied knowledge the STNA's were cleaning those rooms. Interview on 12/07/23 at 12:25 P.M. with STNA #22 revealed it was the responsibility of housekeepers to clean the COVID-19 rooms, she denied knowledge the STNA's were cleaning those rooms. Interview on 12/07/23 at 12:29 P.M. with the CCO revealed it was the responsibility of housekeepers (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 to clean the COVID-19 rooms. Level of Harm - Minimal harm or potential for actual harm Interview on 12/07/23 at 1:56 P.M. with the Environmental Services Manager (ESM) #9 revealed they had done room documentation cleaning sheets in the past but did not have any recent documentation available. ESM #9 denied knowledge housekeepers had not been cleaning COVID-19 rooms. A second interview at 2:04 P.M. with ESM #9 revealed he had spoken to the Housekeeping Manager (HM) #24 regarding the cleaning of COVID-19 positive rooms. ESM #9 further stated the HM #24 informed him that she had stayed until 4:00 P.M. to 4:30 P.M. after day shift had left, and cleaned the COVID-19 rooms. Residents Affected - Many Interview on 12/07/23 at 2:08 P.M. with HM #24 alleged she cleaned the COVID-19 rooms daily herself. HM #24 shared that she worked Monday through Friday and admitted she did not clean the rooms on the weekends. HM #24 shared she had informed the STNA's her housekeepers would not clean the COVID-19 rooms, and it would be their responsibility. HM #24 acknowledged she was not directed by anyone at the facility, and she made the decision herself, and added she did not want her staff exposed to COVID-19. HM #24 also acknowledged any agency staff working on the weekend would not be aware housekeeping had become their responsibility. HM #24 stated the STNA's were aware where the cleaning supplies were located but did not provide any further instruction for them for properly disinfecting the COVID-19 rooms. Review of the facility policy Routine Cleaning and Disinfection last revised 05/2020 revealed to clean prior to disinfection as recommended by the manufacturer; the disinfection solution would be prepared fresh daily; manufacturer's recommendation for proper contact time to ensure adequate disinfection. 3. Review of medical record for Resident #23 revealed admission date of 09/08/23. Diagnoses included but were not limited to duodenal ulcer hemorrhage, cystitis, and Alzheimer's Disease. Resident#23 tested positive for COVID on 11/29/23. Review of physician orders revealed an 11/30/23 order for droplet isolation order for COVID-19 for 10 days. Review of medical record for Resident #36 revealed admission date of 08/11/22. Diagnoses included but were not limited to ataxia following stroke and anxiety. Resident #36 had no documented positive COVID-19 result. Further record review revealed Resident #23 and #36 shared a room at the time of the survey. Review of medical record for Resident #34 revealed admission date of 11/1/22. Diagnoses included but were not limited to type two diabetes mellitus, and depression. Resident #34 tested positive for COVID-19 on 11/30/23. Review of physician orders revealed an 11/30/23 order for droplet isolation order for COVID-19 for 10 days. Review of medical record for Resident #27 revealed admission date of 09/10/22. Diagnoses included but were not limited to stroke, and congestive heart failure. Resident #27 had no documented positive COVID-19 result. Further record review revealed Resident #34 and #27 shared a room at the time of the survey. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of medical record for Resident #40 revealed admission date of 04/26/23. Diagnoses included but were not limited to stroke and depression. Resident #40 tested positive for COVID-19 on 12/02/23. Review of physician orders revealed an 12/02/23 order for droplet isolation order for COVID-19 for 10 days. Review of medical record for Resident #15 revealed admission date of 05/06/22. Diagnoses included but were not limited to hypertensive heart disease. Resident #15 had no documented positive COVID-19 result. Further record review revealed Resident #40 and #15 shared a room at the time of the survey. Review of medical record for Resident #22 revealed admission date of 08/11/23. Diagnoses included but were not limited to hemiparesis due to stroke and diabetes mellitus type two. Resident #22 tested positive for COVID-19 on 12/03/23. Review of medical record for Resident #18 revealed admission date of 01/15/21. Diagnoses included but were not limited to muscular dystrophy. Resident #18 had no positive COVID-19 result. Further record review revealed Resident #22 and #18 shared a room at the time of the survey. Review of medical record for Resident #20 revealed admission date of 07/27/23. Diagnoses included but were not limited to COPD and anxiety. Resident #20 tested positive for COVID-19 on 12/04/23. Review of progress notes dated 12/04/23 revealed the physician was notified of positive COVID-19 result and an order was received for droplet isolation. Review of medical record for Resident #33 revealed admission date of 12/30/22. Diagnoses included but were not limited to Parkinson's disease and dementia. Resident #33 had no positive COVID-19 result. Further record review revealed Resident #20 and #33 shared a room at the time of the survey. Record review of the facility provided positive COVID-19 residents and facility census revealed room changes had not been implemented after a positive COVID-19 result. On 12/06/23 at 12:12 P.M. the CCO and Director of Nursing (DON) were asked if they had COVID positive and negative residents in the same room. The CCO answered, we might. At 2:02 P.M. the CCO confirmed there had been COVID positive residents in with negative residents. The residents were separated, and the CCO was unable to provide a reason for the cohabitation and stated, they should have been moved. On 12/06/23 at 4:11 P.M. the DON reported all residents were tested for COVID-19 and there were no positive results. Review of CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed it is recommended for a patient with suspected or confirmed COVID-19 infection to be in a single-person room. The door should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366263 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grace Brethren Village 1010 Taywood Road Englewood, OH 45322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. This deficiency represents non-compliance investigated under Complaint Number OH00148835. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366263 If continuation sheet Page 5 of 5